Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Apr;30(3):393-402.
doi: 10.1111/jep.13953. Epub 2023 Dec 10.

Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care

Benjamin Djulbegovic  1 , Iztok Hozo  2 , Adam Cuker  3 , Gordon Guyatt  4
Affiliations

Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care

Benjamin Djulbegovic et al. J Eval Clin Pract. 2024 Apr.

Abstract

Background: Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances.

Methods: We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations.

Results: We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%.

Conclusions: The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.

Keywords: clinical practice guidelines; decision analysis; evidence‐based medicine; personalized decision‐making; predictive modelling.

PubMed Disclaimer

References

REFERENCES

    1. Graham R, Mancher M, Wolman DM, Greenfield S, Steinberg E, eds. Clinical Practice Guidelines We Can Trust. Institute of Medicine, National Academies Press; 2011.
    1. Djulbegovic B, Hozo I. Formulating management strategies using fast‐and‐frugal trees (a decision tool to transform clinical practice guidelines and clinical pathways into decision support at the point of care). Cancer Treat Res. 2023;189:67‐75. doi:10.1007/978-3-031-37993-2_5
    1. Mercuri M, Baigrie B, Upshur REG. Going from evidence to recommendations: can GRADE get us there? J Eval Clin Pract. 2018;24(5):1232‐1239. doi:10.1111/jep.12857
    1. Kent DM, Paulus JK, van Klaveren D, et al. The predictive approaches to treatment effect heterogeneity (PATH) statement. Ann Intern Med. 2020;172(1):35‐45. doi:10.7326/m18-3667
    1. Mercuri M, Gafni A. Reflecting on evidence based medicine, person centered medicine and small area variations: how contemporary frameworks for medicine address (or not) the needs of the individual patient. Eur J Person Centered Healthcare. 2018;6(3):454‐461.

Publication types

LinkOut - more resources